Potential effects of angiogenesis-related factors on the severity of APAC and surgical outcomes of trabeculectomy

Background

EPO (erythropoietin) and PDGF (platelet derived growth factor) families are thought to be associated with angiogenesis under hypoxic condition. The sharp rise of intraocular pressure in acute primary angle closure (APAC) results in an inefficient supply of oxygen and nutrients. We aimed to measure the expression of EPO and PDGF family members in APAC eyes and demonstrate their associations with APAC’s surgical success rate.

Methods

Concentrations of EPO, PDGF-AA, -BB, -CC and -DD collected in aqueous humor samples of 55 patients recruited were measured. Before operations, correlations between target proteins and IOP (intraocular pressure) were detected between APAC (acute primary angle closure) and cataract patients. Based on the post-operative follow-up, the effects of EPO and PDGF family members on the successful rate of trabeculectomy were tested.

Results

The levels of EPO, PDGF-CC and -DD were significantly elevated in the APAC group compared to the cataract group. During the post-operative follow-up, EPO, PDGF-CC and -DD showed significant differences between the success and failure groups. In multivariable linear regression analyses, failed filtration surgery was more likely in APAC eyes with higher EPO level. The Kaplan-Meier survival plot suggested that the success rate in eyes with low EPO level was significantly higher than that in eyes with high EPO level.

Conclusion

The levels of EPO, PDGF-CC and -DD were significantly elevated in failure group. EPO level correlated with preoperative IOP and numbers of eyedrops, and higher EPO level in aqueous humor is a risk factor for trabeculectomy failure. It can be a biomarker to estimate the severity of APAC and the success rate of surgery. The investigation of mechanism of EPO in APAC a may have potential clinical applications for the surgical treatment of APAC.

Trends in Surgical Glaucoma Treatment in Germany Between 2006 and 2018

Background/Aims

Surgical procedures in ophthalmology underlie variations over different time periods and are strongly dependent on the technical process and the invention of innovative surgical techniques. Especially, in glaucoma surgery a lot of surgical devices and techniques have been introduced during the last years. Until now, the use of these newer techniques has not been shown on a robust data basis. We herein present the numbers of different types of glaucoma surgeries performed at German hospitals between 2006 and 2018.

Methods and Design

The quality reports of hospitals in Germany from 2006 to 2018 were analyzed concerning all procedural codes for glaucoma surgery and intervention. Especially, the change in usage of "classical" and "modern" surgical techniques (MIGS: "minimally invasive glaucoma surgery") or devices was compared.

Results

The number of glaucoma procedures performed increased by 75% from 27,811 in 2006 to 48,794 in 2018. Absolute numbers of trabeculectomies, goniotomies, ab externo trabeculotomies and to a certain level cyclodestructive procedures decreased during the examined years while use of MIGS has increased in absolute and relative numbers since 2012. From 2015 a strong increase in the usage of XEN implants could be seen. Drainage implants (such as Baerveldt/Ahmed) showed stable absolute numbers over the time period covered. Absolute numbers of laser trabeculoplasty peaked in 2014 and decreased afterwards. Iridotomies and iridectomies increased by 120%/248% over the whole period.

Conclusion

Our data show a trend towards the modern surgical options and especially MIGS during the recent years. Classical procedures showed a decrease in total numbers emphasized from 2013. These numbers confirm the assumption that modern glaucoma surgery is becoming more and more popular and established in German hospitals.

Real-world Surgical Outcomes of Primary Angle-closure Glaucoma

Purpose

To evaluate surgical outcomes of the four common procedures utilized for primary angle-closure glaucoma (PACG).

Methods

A retrospective study of survival rate in surgical management of PACG was conducted in a referral eye center. One hundred and ninety-nine eyes from 173 PACG patients were collected for chart review. The procedures used were phacoemulsification (PE), combined PE with goniosynechialysis (PE-GSL), combined PE with trabeculectomy (PE-Trab), and trabeculectomy alone. Failure was defined as postoperative IOP >21 mmHg in patients who needed second surgical intervention or those who had IOP <5 mmHg with loss of light perception. Cumulative survival rates, risk of surgical failure, and complications were analyzed.

Results

PE, PE-GSL, PE-Trab, and trabeculectomy were performed in 84 eyes (42.2%), 76 eyes (38.2%), 21 eyes (10.6%), and 18 eyes (9%), respectively. Cumulative survival rates at 60 months were 13%, 55%, 42% and 43%, respectively. Cox regression analysis indicated that each mmHg IOP increased, the risk of surgical failure decreased by 13% (adjusted hazard ratio (HR) 0.87; 95%CI: 0.84-0.93, p<0.001).

Conclusion

Real-world surgical outcomes of PACG showed that PE alone had a low survival rate of 13% in 60-month follow-up whereas PE-GSL achieved the highest rate of 55%. PE-GSL should be initially considered for management of PACG, since it can restore and sustain the physiologic aqueous pathway and preserve the conjunctiva for future filtering surgery if needed.

Trabeculectomy with Mitomycin-C in Post-Traumatic Angle Recession Glaucoma in Phakic Eyes With no Prior Intraocular Intervention

PURPOSE

: To evaluate the outcomes of primary trabeculectomy with mitomycin-C (trab MMC) in phakic eyes with post-traumatic angle recession glaucoma with no prior intraocular surgeries.

METHODS

: We included 32 phakic eyes of 32 patients who underwent trab MMC between January-2002 and December-2017. Complete success was IOP between 6 and 21 mm Hg without anti-glaucoma medications (AGM) and failure was when IOP >21 mm Hg with AGM or need for additional intervention for IOP control or loss of light perception.

RESULTS

: Thirty-two eyes of 32 subjects with a mean age (± standard deviation) of 30.6 ± 12.6 years were included. The majority were male (97.6%) and the major cause of blunt trauma were sports injury in 28/32 eyes (88%) and 24/32 eyes (75%) had >180-degree angle recession. The Median (interquartile range) follow-up duration was 1.3 years (0.3,3.5). There was significant IOP reduction at 1-year postoperatively (34 (28,40) to 13 (12,16) mm Hg; p < .001). The median postoperative AGM at 1-year was significantly less (4 (3,4) to 0; p < .001) with stable Log MAR visual acuity (p = .24). The complete survival of trab MMC was 88% at 1 year and was 77% from 2 to 5 years. Complications were intraoperative vitreous prolapse needing limited vitrectomy in two eyes and postoperative choroidal detachment in two eyes that resolved with conservative management. The contralateral eyes of three patients (9.7%) developed elevated IOP during the follow-up period.

CONCLUSION

: Trabeculectomy with mitomycin-C in phakic eyes with traumatic angle recession glaucoma showed good safety and efficacy in the medium-term follow-up. The contralateral fellow eye needs monitoring for glaucoma in these patients.

The Effect of a Triple Combination of Bevacizumab, Sodium Hyaluronate and a Collagen Matrix Implant in a Trabeculectomy Animal Model

Currently available anti-scarring treatments for glaucoma filtration surgery (GFS) have potentially blinding complications, so there is a need for alternative and safer agents. The effects of the intrableb administration of a new combination of the anti-VEGF bevacizumab, sodium hyaluronate and a collagen matrix implant were investigated in a rabbit model of GFS, with the purpose of modulating inflammation, angiogenesis, fibroblast migration and fibrogenesis in the wound healing process. A comparative-effectiveness study was performed with twenty-four rabbits, randomly assigned to the following treatments: (a) biodegradable collagen matrix implant (Olo), (b) bevacizumab-loaded collagen matrix implant (Olo-BVZ), (c) bevacizumab-loaded collagen matrix implant combined with sodium hyaluronate (Olo-BVZ-H5) and (d) sham-operated animals (control). Rabbits underwent a conventional trabeculectomy and were studied over 30 days in terms of intraocular pressure and bleb characterization (height, area and vascularity in central, peripheral and non-bleb zones). Histologic differences among groups were further evaluated at day 30 (inflammation, total cellularity and degree of fibrosis in the area of surgery). Local delivery of bevacizumab (Olo-BVZ and Olo-BVZ-H5) increased the survival of the filtering bleb by 21% and 31%, respectively, and generated a significant decrease in inflammation and cell infiltration histologically 30 days after surgery, without exhibiting any local toxic effects. Olo-BVZ-H5 showed less lymphocyte infiltration and inflammation than the rest of the treatments. Intraoperative intrableb implantation of bevacizumab, sodium hyaluronate and a collagen matrix may provide an improved trabeculectomy outcome in this model of intense wound healing. This study showed an effective procedure with few surgical complications and a novel combination of active compounds that offer new possibilities to improve the efficacy of filtration surgery.

A Retrospective Comparison of Trabeculectomy, Baerveldt Glaucoma Implant, and Microinvasive Glaucoma Surgeries in a Three-Year Follow-Up

Purpose: This retrospective study aimed to evaluate the safety and efficacy of MIGS (Xen® and Cypass®) compared to trabeculectomy and Baerveldt® implants.Patients and Methods: This single-center study included patients from the Ophthalmic Hospital of Turin between January 2015 and 2018.Efficacy was assessed based on the intraocular pressure and the number of medications necessary to control IOP at 1, 3, 6, 12, 24, and 36 months and the potential complications. Complete surgical success was defined as IOP ≤ 21 mmHg, with no medication or additional glaucoma surgery. Qualified success was defined as IOP ≤ 21 mmHg with the reintroduction of topical medications. Our third measure of success was a delta IOP reduction greater than 20% compared to baseline.Results: The delta IOP compared to the baseline was significant at every instance, except in the Xen® implant group. The average IOP distribution at different time points was significant, except at 1 and 12 months. The delta of the medication number compared to the baseline was significant at every instant. All three methods of success were analyzed using a Kaplan-Meier survival curve that identified a significant difference on the success rates of Xen®-trabeculectomy, Xen®-Baerveldt®, and Cypass®-Baerveldt®.Conclusion: MIGS can reduce the number of medication classes, thus increasing patient compliance and reducing topical ocular toxicity and general costs. Trabeculectomy remains the most effective option but still presents a percentage of failures that might increase during follow-up.

The Efficacy and Safety of Trehalose in Primary Trabeculectomy with Mitomycin C: A Report of Early Findings

Objective

To compare bleb morphology and tear tests of glaucoma patients who used trehalose and those who did not use after primary trabeculectomy with mitomycin C (MMC) during the early post-operative period.

Methods

This retrospective study included two groups: Group 1 using Trehalose + hyaluronic acid (THA) after primary trabeculectomy with MMC (n = 19) and Group 2 undergoing primary trabeculectomy with MMC (n = 16). The preoperative and postoperative intraocular pressure (IOP), the results of Schirmer, and tear break-up time tests were analyzed. Postoperative bleb morphology was also evaluated at the 1st day, and 1st and 2nd weeks, and 1st and 2nd months.

Results

There was no statistically significant difference in preoperative IOP, Schirmer test or tear break-up time between groups. The mean horizontal extent of the blebs was significantly wider in Group 1 at the first week (p= 0.02). Bleb vascularization was also found to be lower in Group 1 at the second week (p= 0.001). The mean bleb height and horizontal extent were significantly higher in Group 1 at the first month (p=0.02, p= 0.03, respectively). The mean bleb horizontal extent was significantly higher in Group 1 at the second month (p= 0.03).

Conclusion

The use of trehalose improved surgical success of primary trabeculectomy with MMC in terms of IOP control, post-operative complications, and bleb morphology during the early postoperative period. Trehalose might contribute to wound healing which led to an ideal bleb.

Long-term success after trabeculotomy in primary congenital glaucoma - a study with up to 35 years follow-up

PURPOSE

To evaluate the surgical success after trabeculotomy for primary congenital glaucoma (PCG) in Denmark in the last 40 years.

METHODS

Retrospective review of medical files on children who all underwent trabeculotomy as the first surgical intervention between January 1rst, 1977 and December 31, 2016. Information on diagnosis and surgical procedures were extracted. Primary outcome was surgical success was defined as intraocular pressure (IOP) < 21 mmHg without medications one year after surgery. Secondary outcome was the number of reoperations needed.

RESULTS

Out of 118 children with PCG, 96 children (144 eyes) had an ab externo trabeculotomy as primary IOP lowering procedure opening Schlemm's channel 4 clock hours into the anterior chamber. Complete surgical success at one year was achieved in 73% (106 of 144 eyes). On the long term, IOP could be controlled by one surgical procedure in 2/3 of children, eight eyes required >5 surgical procedures to control IOP. In 12.1% of children the second glaucoma procedure was performed >5 years after the initial trabeculotomy. There was a tendency towards greater risk of needing a second procedure in patients < 3 months of age at primary trabeculotomy (hazard ratio, HR, 2.01, 95% CI 0.96-4.22) and in boys (HR 2.02, 95% CI 0.97-4.18) and a lower risk of requiring a third surgery if the second surgery was trabeculectomy with MMC.

CONCLUSION

Dedicated follow-up of patients with PCG is essential as the disease may continue to progress even after years of quiescence and some children need multiple surgeries to control IOP. Additional glaucoma procedures are required in 1/3 of children and boys and younger patients seem to be at greater risk.

Success of Primary Trabeculectomy in Advanced Open Angle Glaucoma

Aim

The study assesed trabeculectomy survival in advanced open angle glaucoma (OAG).

Methods

This is a retrospective longitudinal study in advanced OAG undergoing primary trabeculectomy. Clinical and demographic parameters were recorded. Surgical survival (qualified/complete) was calculated by Kaplan–Meier analysis for multiple upper limits of intraocular pressure (IOP) with/without medication (≤21 mmHg, ≤18 mmHg, ≤15 mmHg, ≤12 mmHg); Cox hazard ratio analysis identified parameters influencing survival.

Results

We included 165 eyes from 165 OAG patients: primary forms (POAG) – 86 eyes and secondary (pseudoexfoliative, SOAG) – 79 eyes; mean follow-up interval was 36.21 ± 13.49 months. Clinical parameters were comparable between sub-groups at baseline, except a higher IOP in SOAG vs POAG (36.6 ± 13.2 vs 32.7 ± 11.1 mmHg, p = 0.04); IOP reduction was similar (SOAG vs POAG) 53.93% vs 56.19%, p = 0.45, yet longer hospitalization (8.47 ± 4.39 (SOAG) vs 6.69 ± 3.01 days (POAG), p=0.03) and more medications (0.65 ± 0.24 vs 0.36 ± 0.16, p = 0.05) were needed to achieve comparable final IOP (16.0 ± 9.1 vs 15.1 ± 7.8 mmHg, p = 0.45). Kaplan Meier survival analysis applied for IOP ≤21 mmHg, ≤18 mmHg, ≤15 mmHg and ≤12 mmHg, revealed complete success in 26.2%, 27.3%, 34.5% and 54.6% eyes, respectively; qualified success was found in 45.7%, 48.6%, 77% and 88.6% eyes, respectively. Multiple medications at baseline diminished survival in all tested models (hazard ratio HR > 1, p<0.05), while 5FU+needling improved survival, mostly if combined with lower IOP regime: HR = 0.15, 95% CI = [0.07 −1.12], p = 0.06, if IOP ≤15 mmHg and HR = 0.09, 95% CI = [0.02–1.25], p = 0.06, if IOP ≤12 mmHg.

Conclusion

Trabeculectomy in advanced OAG reached very good survival rates (77% and 88.6%) at 36 months postoperative, if IOP could be maintained ≤15 mmHg, respectively ≤12 mmHg with medication and additional needling+5FU maneuvers. Specific factors influencing survival were identified for each success definition.

Factors affecting the early and mid-term success of needling for early failure of filtering bleb

Purpose:

The purpose of this study is to evaluate the factors affecting the success of needling surgery for early filtering bleb failure after trabeculectomy.

Methods:

Patients who underwent a single needling surgery within 3 months after trabeculectomy were retrospectively evaluated. Glaucoma type, intraocular pressure (IOP), and medical treatments before trabeculectomy; the presence of hypotony after trabeculectomy; bleb type; IOP before needling; lens status; complications; IOP after 1, 6, and 12 months; and medical treatments after needling were recorded. Risk factors were evaluated for complete success at 1, 6, and 12 months after needling.

Results:

Thirty-three eyes of 33 patients were analyzed. The mean IOP after needling at 1, 6, and 12 months was 16.09 ± 3.70, 15.64 ± 2.68, and 15.79 ± 2.61 mmHg, respectively. The mean age of the patients was 53.97 (25–79) years. The mean IOP after needling at 1, 6, and 12 months was 16.09 ± 3.70, 15.64 ± 2.68, and 15.79 ± 2.61 mmHg, respectively. The pre-needling IOP and IOP decrease on the first day affected the complete and qualified success at 1, 6, and 12 months, but the glaucoma type, presence of hypotony after trabeculectomy, lens status, interval between trabeculectomy and needling, and bleb type were not found to affect success. In the receiver operating curve analysis, the pre-needling IOP value was found to be significant in determining complete success. Complete success at 1 month was more likely when the pre-needling IOP cutoff value was <24.5 mmHg.

Conclusion:

According to the results of single needling surgery performed within 3 months after trabeculectomy, the pre-needling IOP and IOP decrease with needling were found to be factors affecting success. Regardless of the time between the primary trabeculectomy and needling, effective needling will be successful before the IOP rises to high levels. Keeping the IOP at low values with medical treatment until the needling process is performed will have a positive effect on success.

Effect of dexmedetomidine on intraocular pressure as an additive in peribulbar block during glaucoma surgery

Purpose:

The purpose of this study is to assess the effect of dexmedetomidine on intraocular pressure (IOP) as an additive in peribulbar injections in glaucoma surgeries.

Methods:

A prospective, randomized, double-blind, parallel assignment interventional study was conducted for patients undergoing glaucoma surgeries at a tertiary eye care hospital in North India. Patients were randomized to two groups, Dexmed group and Placebo group. In the Dexmed group, dexmedetomidine (0.4 μg/kg body weight) was given as an additive along with peribulbar block. The primary outcome was change in IOP pre- and postperibulbar injections (IOP before the block, and after 5 and 15 min of the block). Secondary outcome measures were onset of block, adverse effects (bradycardia, hypotension, respiratory depression, and level 4 sedation), and surgeon satisfaction.

Results:

A total of 104 patients were randomized, 52 each in the Dexmed group and Placebo group. The percentage decrease in IOP was significantly more in the Dexmed group than in the Placebo group both at 5 and 15 min' post block (P < 0.05). At 5 min, the mean percent decrease in IOP in Dexmed group was -10.48, whereas it was 2.85 in the Placebo group. At 15 min, the mean percent decrease in IOP was -22.59 and -9.42 in the Dexmed and Placebo group, respectively. There was no significant difference between the two groups in the onset of block and adverse effects. Surgeon satisfaction was significantly greater in the Dexmed group than the Placebo group (P < 0.05).

Conclusion:

Dexmedetomidine lowers IOP significantly in patients undergoing glaucoma surgeries with safe hemodynamic changes and sedative effect.

Cross-linked hyaluronic acid viscoelastic scleral implant in trabeculectomy

Purpose:

Patients with glaucoma undergoing trabeculectomy develop bleb cicatrix causing poor postoperative intraocular pressure (IOP) control and low success rates. Several approaches have been explored over the years for better outcomes. This study assesses the safety, efficacy, and outcome of trabeculectomy with HealaFlow^® (Anteis S. A, Geneva, Switzerland), a high-molecular-weight cross-linked hyaluronic acid viscoelastic gel, and comparing it with the antimetabolite Mitomycin-C (MMC).

Methods:

A prospective, interventional, case-controlled study conducted at a tertiary care hospital in Southern India on 60 eyes of patients requiring trabeculectomy divided in two groups – HealaFlow scleral implant and adjuvant low-dose MMC (0.1 mg/mL). Postoperative IOP reduction along with bleb morphology was assessed over follow-up at 1 week, 1 month, 3 months, 6 months, and 12 months.

Results:

Preoperatively IOP in the two groups was statistically similar. Postoperative IOP on day 1 had statistically significant reduction in both groups with greater reduction in MMC group. However, by 12 months, the IOP reduction was statistically similar in both groups, i.e., 46.24% (to 11.04 ± 2.55 mmHg) and 54.47% (to 11.99 ± 3.37 mmHg) in HealaFlow^® group and MMC group, respectively (P > 0.05). The bleb morphologies were similar and complications were seen equally, which resolved by 4 weeks. A complete success rate of 89.29% and a qualified success rate of 10.71% were observed equally in both groups.

Conclusion:

Absorbable biosynthetic cross-linked hyaluronic acid and low-dose MMC are equally safe and efficacious in trabeculectomy with significant IOP reduction and good bleb morphology. Therefore, it is a novel substitute for MMC.

Small incision cataract surgery with trabeculectomy versus phacoemulsification trabeculectomy in pseudoexfoliation glaucoma

Purpose:

This study aims to evaluate efficacy and outcomes of manual small incision cataract surgery with trabeculectomy (Group 1) and phacoemulsification with trabeculectomy (Group 2) in pseudoexfoliation glaucoma (PXG).

Methods:

In this retrospective comparative observational case series, All patients with PXG who underwent either small incision cataract surgery or phacoemulsification with trabeculectomy from 2011-2015 were studied. Data compared included best corrected visual acuity (BCVA), intraocular pressure (IOP), total surgical time, and incidence of intra/postoperative complications.

Results:

A total of 82 (Group 1) and 64 (Group 2) subjects were included for the study. The baseline IOP and anti-glaucoma medications in both groups were comparable pre-operatively (group 1 = 26 ± 10.3 mmHg, group 2 = 23 ± 13.9 mmHg, P = 0.1). The IOP at final follow up between the two groups was not statistically significant (group 1 = 12 ± 3.2 mmHg, group 2 = 14 ± 1.8 mmHg, P = 0.2). The average total time of surgery (group 1 = 40 ± 21.6 min, group 2 = 34 ± 14.8 min, P = 0.4) was not statistical significant between groups. The incidence of post-operative complications were similar in both groups (P = 0.95).

Conclusion:

Manual small incision cataract surgery with trabeculectomy is noninferior in PXG patients with comparable surgical outcomes, when compared with phacoemulsification with trabeculectomy.

Intracameral Bevacizumab Versus Sub-Tenon's Mitomycin C as Adjuncts to Trabeculectomy: 3-Year Results of a Prospective Randomized Study

Conjunctival wound healing determines success after filtration surgery and the quest for better antifibrotic agents remains active. This study compares intracameral bevacizumab to sub-Tenon’s mitomycin C (MMC) in trabeculectomy. Primary open-angle or exfoliative glaucoma patients were randomized to either bevacizumab (n = 50 eyes) or MMC (n = 50 eyes). The primary outcome measure was complete success, defined as Intraocular Pressure (IOP) > 5 mmHg and ≤21 mmHg with a minimum 20% reduction from baseline without medications. Average IOP and glaucoma medications decreased significantly in both groups at all follow-up points compared to baseline (p < 0.001), without significant difference between groups at 3 years (IOP: bevacizumab group from 29 ± 9.4 to 15 ± 3.4 mmHg, MMC group from 28.3 ± 8.7 to 15.4 ± 3.8 mmHg, p = 0.60; Medications: bevacizumab group from 3.5 ± 0.9 to 0.5 ± 1, MMC group from 3.6 ± 0.7 to 0.6 ± 1.1, p = 0.70). Complete success, although similar between groups at 3 years (66% vs. 64%), was significantly higher for bevacizumab at months 6 and 12 (96% vs. 82%, p = 0.03; 88% vs. 72%, p = 0.04, respectively) with fewer patients requiring medications at months 6, 9 and 12 (4% vs. 18%, p = 0.03; 6% vs. 20%, p = 0.04; 8% vs. 24%, p = 0.03, respectively). Complication rates were similar between groups. In conclusion, intracameral bevacizumab appears to provide similar long-term efficacy and safety results as sub-Tenon’s MMC after trabeculectomy.

Ocular Surface Changes Associated with Ophthalmic Surgery

Dry eye disease causes ocular discomfort and visual disturbances. Older adults are at a higher risk of developing dry eye disease as well as needing for ophthalmic surgery. Anterior segment surgery may induce or worsen existing dry eye symptoms usually for a short-term period. Despite good visual outcomes, ocular surface dysfunction can significantly affect quality of life and, therefore, lower a patient’s satisfaction with ophthalmic surgery. Preoperative dry eye disease, factors during surgery and postoperative treatment may all contribute to ocular surface dysfunction and its severity. We reviewed relevant articles from 2010 through to 2021 using keywords “cataract surgery”, ”phacoemulsification”, ”refractive surgery”, ”trabeculectomy”, ”vitrectomy” in combination with ”ocular surface dysfunction”, “dry eye disease”, and analyzed studies on dry eye disease pathophysiology and the impact of anterior segment surgery on the ocular surface.

Merits of conjunctival frill incision in reducing trabeculectomy-induced astigmatism and patient discomfort

Purpose

To compare results of a novel "conjunctival frill/smile incision" on surgically induced astigmatism (SIA) and patient discomfort vs conventional trabeculectomy in the initial postoperative period.

Methods

Sixty trabeculectomy cases were subjected to either conjunctival frill incision, performed 1.5-2.0 mm from the limbus (study group) or conventional fornix-based conjunctival flap (control group). Corneal astigmatism and suture-induced discomfort were assessed by keratometry and a self-devised patient questionnaire, respectively.

Results

Both groups generated a "with the rule" SIA, which was 1.77 vs 2.42 at 1 week and reduced to 1.27 vs 1.8 in the study vs control group, after removal of sutures - both scleral flap releasable and conjunctival at 1 month. Patient discomfort score revealed enhanced comfort in 37% of patients (study group) vs 17% (control group) during the early postoperative period. After 1 month of surgery, good comfort was regained in all cases.

Conclusion

This novel suturing technique results in reduced SIA, patient discomfort during the 1st month after trabeculectomy.

An Ex-Press implant versus trabeculectomy in a fibrotic bleb with late failure after previous trabeculectomy

AIM

To compare the outcome of an Ex-Press implant and subscleral trabeculectomy (SST) in the management of glaucoma after previous trabeculectomy on a fibrotic bleb.

METHODS

This randomized prospective study included 28 eyes from 28 patients (age range: 42-55y) with primary open angle glaucoma (POAG) presented with elevated intraocular pressure (IOP) with fibrotic bleb despite previous SST for more than 4mo. The eyes enrolled in the study were divided into two groups: group I (subjected to Ex-Press implant surgery) and group II [subjected to SST with mitomycin C (MMC)]. The follow-up continued one year after surgery to evaluate IOP, visual acuity (VA), visual field (VF), and postoperative complications.

RESULTS

A significant decrease in IOP was found in both groups with a higher reduction in Ex-Press implant surgery with the mean IOP of 14.50 mm Hg (P=0.001), while the SST group recorded the mean IOP of 16.50 mm Hg (P=0.001) after one year. However, the difference between the two groups in terms of the decrease in IOP was insignificant. Fewer postoperative complications were recorded in the Ex-Press implant surgery and more cases requiring further anti-glaucomatous medications were seen in the SST group. Both groups showed stability in terms of VA and VF.

CONCLUSION

Ex-Press implant surgery and SST with MMC are two surgical alternatives for controlling IOP in late failure that occurs more than 4mo after previous SST with a fibrotic bleb. However, Ex-Press shunt is a safer surgery with fewer complications.

Surgical Outcomes of Primary Congenital Glaucoma in Children Under One Year from the Nile Delta

Purpose

To present outcomes of surgical management of primary congenital glaucoma (PCG) in children less than one year of age in a population based at the Nile Delta.

Methods

A retrospective review of medical records of patients with PCG less than one year of age at presentation who underwent surgical intervention in a tertiary care facility based at the Nile Delta. All patients underwent measurement of intraocular pressure (IOP), horizontal corneal diameter (HCD), cup-to-disc ratio (CDR) before and after surgery and a minimum of 6 months follow up was required. Surgical success was defined as IOP less than 22mmHg without medications and without progression of main disease parameters.

Results

The review revealed 44 eyes of 26 consecutive patients who underwent surgical treatment for PCG. Average age at surgery was 5.2 months and mean follow up was 18.5 months. Preoperative IOP was 28.5±4 mmHg, HCD was 13.7±0.7mm, and CDR (when visible) was 0.65±0.18. A total of 69 surgical procedures were performed with an average of 1.56 procedures per eye. Postoperative IOP was 13.3±4.8 mmHg, HCD was 12.8±0.9mm, and CDR was 0.3±0.2 (P<0.0001). Surgical success was achieved in 32 eyes (72.7%) while sight-threatening postoperative complications were reported in 3 eyes.

Conclusion

Surgical management of PCG younger than one year of age achieved good success rate in the region of the Nile Delta with low rate of visually significant postoperative complications. However, larger studies with longer follow up are needed to fully reveal the overall characteristics of PCG in the region.

Trabeculectomy: is releasable suture trabeculectomy a cause of better bleb?

Purpose: To compare the outcome of fixed suture trabeculectomy with releasable suture trabeculectomy in terms of IOP control, bleb morphology, complications and need of antiglaucoma medication post-surgery.

Methods: This study enlisted 200 cases of open angle glaucoma, whose IOP was uncontrolled despite maximal medication. Trabeculectomy was performed using releasable suture in one group of 100 patients and fixed suture in another group of 100 with mitomycin 0.02% in both groups. The study was randomized, the method being the simple randomization. Fornix based trabeculectomy was done in both groups. Two 10-0 nylon releasable sutures were used at two corners of the rectangular flap and one fixed 10-0 vicryl suture was used in the center of the flap. Two mattress sutures (conjunctiva cornea) were also used. Essentially, all the sutures were removed postoperatively over a period of 2-4 weeks depending upon the level of IOP. Mitomycin c 0.02% was used in both groups.

Results: The mean preoperative intraocular pressure was 33 ± 12 mmHg in the single suture group and 39 ± 13 mmHg in the releasable suture group (p). We observed a highly significant reduction of intraocular pressure at all times in both groups compared with the preoperative intraocular pressure (P, 0.0001). There was an obvious difference between the bleb morphology between conventional trabeculectomy and releasable suture trabeculectomy. Blebs in releasable suture trabeculectomy were more diffuse, low lying and presented a more ideal vascularity.

Conclusion: Releasable suture trabeculectomy is a far much better technique than conventional trabeculectomy. Results are very good in terms of IOP control, post-operative complications, and bleb morphology. They may possibly have a role in wound modulation thereby achieving an ideal bleb, though more large sample studies need to be done.

Intraocular pressure control after combined phacotrabeculectomy versus trabeculectomy alone

PURPOSE

We compared the efficacy and safety of trabeculectomy and phacotrabeculectomy in patients with glaucoma.

MATERIALS AND METHODS

We retrospectively analyzed consecutive patients who underwent trabeculectomy or phacotrabeculectomy. Patients in the trabeculectomy group were pseudophakic. We established three different intraocular pressure (IOP) thresholds (A: <21 mmHg, B: <18 mmHg, and C: <15 mmHg) to measure complete (without medication) and qualified (with medication) success. Success criteria were analyzed through Kaplan-Meier survival curves.

RESULTS

Sixty-seven eyes were included (40 trabeculectomy, 27 phacotrabeculectomy). The mean follow-up period was 25.70 ± 14.439 months. The baseline characteristics were similar between the groups. The complete and qualified success rates according to criterion C were significantly higher in the trabeculectomy group (p = 0.033, p = 0.021, respectively); however, there was a trend toward a higher success rate for all criteria in favor of trabeculectomy. Bleb needling was more frequent in the phacotrabeculectomy group. The mean IOP significantly decreased from 26.46 ± 7.07 to 12.27 ± 4.06 at 12 months (p < 0.001). The final mean IOP was significantly lower in the trabeculectomy than in the phacotrabeculectomy group (10.95 ± 3.08 vs 13.00 ± 4.56, p = 0.0003).

CONCLUSION

In pseudophakic eyes, trabeculectomy alone achieves a higher success rate, lower mean IOP, and less frequent bleb needlings. More frequent follow-up and prolonged postoperative use of high-dose topical steroids should be considered in patients undergoing phacotrabeculectomy.

Neovascularization of angle following trabeculectomy augmented with mitomycin-C

The purpose of this study was to report a case of neovascularization of angle (NVA) following trabeculectomy with mitomycin-c (MMC) in a patient with primary open-angle glaucoma. This case report describes a 68-year-old woman who developed NVA and hyphema 2 weeks following an uneventful trabeculectomy with MMC. Trabeculectomy may be associated with serious and vision-threatening complications such as hypotony, suprachoroidal hemorrhage, endophthalmitis, and bleb-related complications. However, neovascularization of the anterior segment is not a commonly reported complication. Neovascularization of the anterior segment is a rare postoperative complication that usually occurs following strabismus or retinal detachment surgeries. The underlying ischemic trigger for anterior segment neovascularization is usually a posterior segment pathology or carotid artery insufficiency. These causative factors were excluded in our patient by lack of any abnormal finding in fundus fluorescein angiography and carotid Doppler ultrasonography. The patient received three subconjunctival bevacizumab injections (1.25 mg/0.1 ml) with frequent topical steroids and showed marked regression of the neovessels. The bleb was functional, and intraocular pressure remained at low teen afterward. NVA following trabeculectomy without any posterior segment or carotid pathologies responded well to subconjunctival bevacizumab and topical steroids.

ExPress mini shunt device with trabeculectomy surgery in patients with uncontrolled glaucoma of Middle Eastern descent

PURPOSE:

The aim of this study is to assess the efficacy and safety of ExPress mini shunt in glaucoma patients of Middle Eastern descent.

METHODS:

This is a prospective cohort study. Uncontrolled glaucoma patients were subjected to ExPress mini-shunt implant. Pre- and post-operative glaucoma clinical indices were measured and compared. Both intra- and postoperative complications and surgical success rates were assessed. In addition to comparing a group of combined ExPress mini-shunt implant with cataract surgery versus ExPress mini-shunt implant alone.

RESULTS:

A total of 35 eyes of 31 patients were involved. The most common type of glaucoma was primary open-angle glaucoma in 13 eyes (37.1%). Fourteen eyes (40.0%) were combined ExPress device with cataract surgery. The mean intraocular pressure (IOP) (±standard deviation) at the last visit dropped from 24.6 mmHg (±8.3) to 13.9 mmHg (±4.5). There was a significant reduction in the number of postoperative glaucoma medications from 3.0 ± 0.5 to 1.3 (±0.7). In cases combined with cataract extraction, the patients required fewer anti-glaucoma medications. Complete success was achieved in 22 eyes (63%) and qualified success was achieved in 9 eyes (26%), whereas 4 eyes (11%) were considered a failure. The two most common complications encountered were hypotony (28.6%) and hyphema (11.4%).

CONCLUSION:

Among the studied population of patients, ExPress offers IOP reduction that is comparable to reported rates following standard trabeculectomy. Postoperative hyphema was encountered at a slightly higher rate.

Long-Term Follow-Up After Successful Trabeculectomy: A Case Report of Reversal of Cupping and Recovery of Visual Field Progression

Glaucoma is one of the leading causes of blindness worldwide, and reduction of intraocular pressure (IOP) is the only available evidence-based treatment that reduces visual field deterioration in glaucoma. We present a representative case of structural recovery and recovery of visual field progression after successful trabeculectomy (TLE) with long-term follow-up. A 35-year-old woman with glaucoma visited our hospital in 2008. The IOP in her right eye was 11 mmHg at the first visit, and subsequently increased to values in the high teens to 20 mmHg despite treatment with anti-glaucoma eye drops. During this period, the progression of this eye's visual field deterioration was fast (mean deviation [MD] slope = -0.63 dB/year) and the optic disc cupping was advanced. In the seven-year period after successful TLE in 2014, the IOP declined to between 8 and 12 mmHg without any anti-glaucoma medication. During the first two years after TLE, the MD values were poorer than those before TLE. However, by 2020, MD values improved gradually to a state better than that before the surgery (MD slope during this period was +0.75 dB/year). The appearance of the optic disc was monitored using fundus photography, which showed optic disc morphological changes during topical glaucoma medication before and after TLE. In particular, a remarkable reversal of optic disc cupping enlargement started at two weeks after TLE, and the optic disc shape in 2021 was similar to that in 2008. Minimally invasive glaucoma surgeries are often preferred; however, our findings suggest that successful TLE followed by long-term rigorous IOP control can result in structural recoveries. Additionally, despite the deterioration in visual field in the early years after TLE, in the long term, it may settle down to the same level before the surgery with recovery of visual field progression, which may be a part of functional recovery.

Predictability of ab-interno trabeculectomy success in the subsequent eye: A contralateral eye comparison study

BACKGROUND

To determine whether the outcome of the first eye may serve as a predictor for intraocular pressure (IOP)-lowering effectiveness in the second eye following bilateral ab interno trabeculectomy.

METHODS

This retrospective single-centre study included 168 eyes from 84 participants, who underwent combined Trabectome surgery with phacoemulsification cataract surgery in a hospital setting. The clinical endpoint was defined as either 'success' or 'failure' based on four separate scores at the longest follow-up time point: IOP at follow-up <21 mm Hg (Score A) or IOP < 18 mm Hg (Score B), without re-surgery and IOP reduction >20%; IOP ≤15 mm Hg without re-surgery and IOP reduction ≥40% (Score C); and the sole absence of re-surgery according to the discretion of the surgeon (Score D).

RESULTS

No significant difference was observed between the outcomes of first and second eyes. The frequency of success in the second eye after effective surgery in the first eye significantly exceeded that after prior failure. Within our analysis, the probability calculations determined a 75% chance of success following prior success for Score A. If surgery in the first eye failed, the chance of success in the subsequent eye was 37%. The corresponding probabilities were 79% and 32% for Score B, 56% and 9% for Score C, and 99% and 50% for Score D.

CONCLUSION

The results of our study offer a useful tool to assess the success of subsequent eye surgeries based on the outcome in the initial eye, owing to the high predictive potential.

The Effect of Antiglaucoma Procedures (Trabeculectomy vs. Ex-PRESS Glaucoma Drainage Implant) on the Corneal Biomechanical Properties

The aim of this study is to investigate the effect of two antiglaucoma procedures, namely trabeculectomy and Ex-PRESS mini-shunt insertion on the biomechanical properties of the cornea. This is a prospective study. Thirty patients (30 eyes) were included in the study. Nineteen eyes had an Ex-PRESS shunt inserted (Group 1) and 11 had trabeculectomy (Group 2). The examination time points for both groups were one to three weeks preoperatively and at month 1, 6, and 12 postoperatively. Corneal biomechanical properties (corneal hysteresis (CH) corneal resistance factor (CRF)) were measured with the Ocular Response Analyzer (ORA). In group 1, CH was significantly increased at 6 and 12 months compared to baseline values. Corneal hysteresis was also higher at 1 month postoperatively, but this increase did not reach statistical significance. In group 2, the CH was significantly increased at all time points compared to the preoperative values. CRF decreased at all time points postoperatively compared to the preoperative values in both groups. The difference (preoperative values to postoperative values at all time points) of the CH and CRF between the two groups was also compared and no significant differences were detected between the two surgical techniques. Trabeculectomy and the EX-PRESS mini-shunt insertion significantly alter the corneal biomechanical properties as a result of the surgical trauma and the presence of the shunt in the corneal periphery. When compared between them, they affect the corneal biomechanical properties in a similar way.